M. Varasteh Kia2, J. K. Canner1, R. J. Battafarano1, S. C. Yang1, E. L. Bush1, M. V. Brock1, E. R. Haut1,3, S. R. Broderick1 1Johns Hopkins University School Of Medicine,Baltimore, MD, USA 2Johns Hopkins Bloomberg School Of Public Health,Epidemiology And Biostatistics,Baltimore, MD, USA 3Johns Hopkins Bloomberg School Of Public Health,Health Policy And Management,Baltimore, MD, USA
Introduction
To restore gastrointestinal continuity following esophagectomy, tubularized stomach is the preferred conduit. In scenarios where the stomach cannot be used non-gastric conduits such as jejunal or colonic interpositions are employed. There are inconsistencies between previous studies examining outcomes associated with the use of non-gastric conduits. Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, we examined perioperative outcomes in patients reconstructed with gastric and non-gastric conduits to better characterize the relative risks of morbidity and mortality associated with these procedures.
Methods
2006 – 2015 ACS-NSQIP esophagectomy cases were separated into gastric and non-gastric conduits based on CPT codes. Emergent and non-cancer resections were excluded. We examined perioperative differences between the two groups using chi-square and nonparametric Wilcoxon rank sum tests. Unadjusted and adjusted risk ratios of postoperative complications were estimated using Poisson regression with robust error variance.
Results
After exclusions, there were 6,321 and 210 patients in the gastric and non-gastric groups, respectively. In unadjusted comparisons, significant differences were identified in 30-day mortality rate (3.32% vs 10.48%, p < 0.001), prolonged hospitalizations (5.30% vs 10.26%; p = 0.02), median length of stay (10% vs 13%; p < 0.001), reoperation rate (14.27% vs 30.43%, p < 0.001) and operative time (342 vs 384 minutes; p < 0.001) between the gastric and non-gastric groups. No significant differences were identified in the occurrence of superficial, deep or organ/space surgical site infection, pneumonia, or readmission. After adjusting for age, gender, ethnicity, history of diabetes, smoking status, history of COPD, weight loss >10% in prior 6 months and BMI, there remained significant differences between groups in 30-day mortality (RR 0.33 [0.22-0.50]) for gastric vs non-gastric conduit), prolonged hospitalization (RR 0.51 [0.30-0.90]), and reoperation (RR 0.46 [0.35-0.61]), respectively (Table 1).
Conclusion
The use of non-gastric conduit interposition following esophagectomy for carcinoma is associated with higher chance of mortality. However, the underlying reasons for this difference could not be identified using ACS-NSQIP data. Limitations of this study include its retrospective nature and the inherent limitations of the ACS-NSQIP dataset. This analysis may help to inform shared decision making when considering alternate conduits for reconstruction for esophageal cancer patients in whom the gastric conduit is not feasible.
